New algorithm aims to better diagnose repeat unsuccessful IVF

Unsuccessful IVF attempts can be stressful, overwhelming and devastating for patients wanting to conceive.
 
And for GPs involved in ongoing fertility counselling, diagnosis of recurrent implantation failure (RIF) can present significant clinical and therapeutic challenges, given the debate on how many previous unsuccessful IVF embryo transfers experts consider as diagnostic criterion.  
 
New research, led by fertility specialists from Melbourne IVF, aims to address these challenges with a new approach that personalises the diagnosis of RIF and is designed help improve patient fertility counselling and planning.
 
According to the authors, RIF is an ‘imprecisely defined disorder lacking a robust scientific basis’ that does not consider important aspects of the IVF treatment process, such as embryo grading or ‘meaningful’ pregnancy outcomes.
 
They believe an updated definition is overdue and are proposing a new algorithm called the theoretical cumulative implantation rate (TCIR), where the calculation is based on objective data to define whether a patient should be diagnosed with RIF.
 
Each embryo transferred following an IVF cycle has a theoretical implantation rate (TIR) based on different factors, such as female age, embryo quality, cycle details, chromosomal normality for tested embryos, and inter-laboratory variability.
 
Lead author and fertility specialist at Melbourne IVF Dr Genia Rozen told newsGP the new concept is also designed to strengthen the patient–doctor relationship.
 
‘It will assist in discussions around the discontinuing of fertility treatment, and lead to the introduction of donor conception possibilities,’ she said.
 
‘In the primary care setting, patients frequently consult their GP following multiple failed IVF cycles. Patients are often going through a really hard time at this point and turn to their trusted family doctor.
 
‘At this point in time, GPs can have the supportive role of guiding and counselling these patients.’
 
In addition to patient support, the TCIR method aims to improve clinical decision making with a more individualised and scientific approach.
 
Dr Rozen highlights that as RIF is ‘not a diagnosis in itself’, the simplified algorithm can reduce unwarranted testing and therapeutic interventions by basing management on one question: What is the number of unsuccessful embryo transfers before further investigations commence to uncover pathology?
 
‘A personalised TCIR takes into consideration all factors which may impact the chance of pregnancy,’ she said.
 
‘In the patient’s reproductive journey, the aim is to improve patient counselling and assist in timings regarding initiating investigations, which are sometimes not strongly evidence based.
 
‘There are challenges with this approach – the data needed to estimate chances of pregnancy from an embryo transferred may not always be at hand. However, even approximate estimation which still incorporates factors which may impact the chance of pregnancy, based on logical and consistent criteria is an attractive prospect.
 
‘This would still provide a more accurate estimation and definition of RIF.’
 
While patients should be aware of their chance of pregnancy success, GPs can assist patients in assessing their theoretical pregnancy rate.
 
‘It’s important for patients to understand their chances of pregnancy with their transferred embryo as well as their theoretical pregnancy chance after a number of transfers,’ Dr Rozen said.
 
‘It often helps to reassure patients that success is still likely [if they continue with treatment], and a stronger recommendation that they should in fact continue with IVF treatment.
 
‘This information also reduces the pressure to commence investigations and/or therapies which are not strongly ground in evidence.’
 
Pilot studies of the proposed TCIR algorithm are expected to be implemented in the general practice setting following establishment of additional refinement of the concept and further expert opinion.
 
Dr Rozen said a more standardised and personalised definition of RIF will not only assist future research and GPs in clinical decision making, but patients planning a pregnancy.
 
‘We hope awareness of this concept will help ease patient anxiety and their desire to try unwarranted diagnostic investigations in IVF,’ she said.
 
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fertility IVF pregnancy recurrent implantation failure reproductive health